Presentation on theme: "Key Concepts –Accountability measures for systems being rosc –What is a rosc –Talk about the how (vs what) of ROSC –How to transform a system –Positioning."— Presentation transcript:
Key Concepts –Accountability measures for systems being rosc –What is a rosc –Talk about the how (vs what) of ROSC –How to transform a system –Positioning systems for the emerging world, antidote for irrelvance
Arthur C. Evans, Ph.D. Philadelphia Department of Behavioral Health and Intellectual disAbility Services & The University of Pennsylvania NYAPRS 29 th Annual Conference ~ Bringing Recovery Home for All September 15, 2011 Recovery in an Era of Health Reform: Building for the Future
Acknowledgements All of the staff of DBHIDS, People in Recovery, Providers and Community Stakeholders
TAKE HOME MESSAGES A Recovery framework is not just compatible with, but essential for behavioral health in the emerging healthcare environment A systems approach must be taken in order to promote recovery Recovery oriented practices can thrive in a managed health care environment, with the right policy framework
Well, where did we come from?
Byberry State Hospital
What was it Like in the Hey Day of Hospitals? Self Contained Communities Most Senior and many lower level staff lived on grounds Many had large farms and other industries Most were geographically isolated Most had little to no scrutiny
Shame of the States Byberry 1946: 6100 patients & Less than 200 clinical staff “As I passed through some of the Byberry wards I was reminded of the pictures of Nazi concentration camps. I entered buildings with naked humans herded like cattle and treated with less concern …children together with adults in every stage of mental deterioration”
The Beginning of the End Deinstitutionalization the policy of moving people with severe mental illnesses out of large state institutions and then closing part or all of those institutions
Impact of Deinstitutionalization In 1955, there were 558,239 people with severe mental illness in the nation's public psychiatric hospitals In 1994, this number had been reduced by 486,620 people – to 71,619
Mental Models In both the case of MH Treatment and Addictions Treatment, the shift in mindset didn’t go far enough Still assumptions about the capacity of individuals “Community Institutionalization” Symptom management and treatment focus Outcomes not determined by the person Etc etc
EXAMINING OUR CURRENT SERVICE SYSTEM: Getting Out of the Treatment Box
A Different Mental Model
3 Approaches to System Transformation Additive Selective Transformational Adding peer and community based recovery supports to the existing treatment system Practice and Administrative alignment in selected parts of the system Cultural, values based change drives practice, community, policy and fiscal changes in all parts and levels of the system. Everything is viewed through the lens of and aligned with recovery oriented care.
“...merely making incremental improvements in current systems of care will not suffice.” Institute of Medicine
What are the Emerging Trends in HealthCare?
HealthCare Reform Likely Trends... Increased accountability and emphasis on outcomes Greater emphasis on empirically supported treatment Greater emphasis on program efficiency Physical Health Integration Addressing diversity and reducing health disparities Greater use of technology (e.g., Health Information Technology)
ROSC Principles of System ManagementConsistent Provisions/Foci of the PPACA Clinical Practices are Aligned with Science Patient-Centered Outcomes Research Institute and Comparative Effectiveness Research will increase the development of evidence informed practice guidelines Individuals and families are in key leadership positions Participants on Key Advisory Boards e.g. Board of Governors for Patient Centered Outcomes Research Institute (3 of 17 are “patients”). Expansion of peer-based workforce, resources for training paraprofessionals. Decision Making is Data Driven, Transparent and Participatory Health Information Technology will facilitate data driven decisions. Data about service quality will be available via the internet to inform decision making Accountability for Quality Improvement and Outcomes is facilitated The National Quality Forum and the Quality Reporting Program will facilitate a national QI strategy Resources and Policies are aligned to Support Effective, Recovery oriented Services Value-based purchasing and value-based insurance design will incentivize the delivery of effective care. The Center for Medicare & Medicaid Innovation will test innovative payment and service delivery models. Strategic Investments in Workforce Development Mental and Behavioral Health Education and Training Grants. The Primary Care Extension Program will educate providers about behavioral health services Connecting the Dots: The Philadelphia Model & Health Care Reform System Management
HOW DO WE PROCEED?
1.Optimize Treatment Services 2.Recovery Support Services 3.Community and Cross Systems Collaborations 4.Fiscal and Administrative Policy & Procedure Alignment Four Building Blocks of a Recovery & Resilience-Oriented System
ROSC: Building Block Strategies Optimize clinical service delivery –Orient and re-engineer services around the goal of long-term recovery with an understanding of their role in that process –Optimize the clinical effectiveness of treatment services through the use of empirically supported treatments, individualized approaches (i.e., co- occurring, trauma informed, culturally competent, developmentally appropriate, etc) Add and integrate recovery support services –Add those recovery support services that are needed to support long- term recovery for individuals and their families –Utilize both free standing and integrated services that are embedded within treatment and add another dimension to the treatment process
ROSC: Building Block Strategies Build Cross-Systems Partnerships and Community Recovery Capital –Goal: resilient and healthy communities –Communities’ capacity to prevent behavioral health challenges, intervene early when they occur and support individuals who are in the recovery process Fiscal and Administrative Policy & Procedures –Ensuring that policy and procedures support the practice changes that have been implemented –Remove administrative & fiscal barriers to recovery-oriented practice
Building Block I: Promote Excellent Treatment Services
Clinical Assessments Changing our Questions: Examples Can you tell me a bit about your hopes or dreams for the future? What kind of dreams did you have before you started having problems with alcohol or drug use, depression, etc.? What are some things in your life that you hope you can do and change in the future? If you went to bed and a miracle happened while you were sleeping, what would be different when you woke up? How would you know things were different?
Implementing Evidence- Based Practice Example: Beck Initiative Partnership with academic institution to Implement Cognitive Therapy throughout the Philadelphia service system Training multiple groups in system, including homeless outreach workers Using evidence to drive clinical care & outcomes Dr. Aaron T. Beck & Dr. Judith S. Beck, Director with “5- Day” Cognitive Therapy Workshop participants Nov. 7, 2007
Day Program Transformation 8 Mental Health Agencies with over 2000 people enrolled since 2007 Average Length of Stay = 15 + years Historical Design: “Maintain” people discharged from the state hospital Site-based programming
New Day Service System: Transformation Goals Focus on community inclusion & the attainment of normalized roles Focus on skill building Integrate substance use treatment into service options
36% decrease in Crisis Utilization for those with at least 1 year in program Study included 611 consumers that had at least one year in Day Program Decrease in Crisis Utilization
Lower Cost of Inpatient Psychiatric Services
PROMOTING HEALTH EQUITY
Reducing Identified Disparities
Geographical Information System (GIS) Techniques Service UtilizationAA Residential Distribution Providers Figure 1Figure 2 Figure 3
Building Block II: Creating a Peer Culture
Peer Support, Culture and Leadership Implementing a Practice versus Developing a Culture: What’s the Difference?
The Creation of Peer Culture Recovering persons on agency boards Developing/empowering informal peer leadership Openly recruiting recovering persons as staff Paid “peer specialists” to provide formalized support Creating a sense of a community where recovering persons helping recovering persons is highly valued Infusing peer self help throughout the service continuum Understanding the unique learning advantages of peer delivered services
Recovery Trainings DBHIDS offers a variety of training programs for both people in recovery and their families, designed to support recovery. They include: Storytelling- using personal stories to inspire others in their own personal journey of recovery. Recovery Training- learning key recovery principals to achieve positive and sustained progress. Group Facilitation Skills Training- how to effectively participate with peers in a group recovery setting. Wellness Recovery Action Plan (WRAP)- how to create your own recovery plan to effectively manage your recovery. Family Training and Advocacy Center- offering a "family perspective" on training and education. Behavioral Health Training & Education Network- providing behavioral health education and support to people in recovery and their families.
Examples of Peer Support Treatment Efforts Recovery coaches and peer specialists Recovery Resource Centers Facilitating linkages Leadership Councils Recovery Check-ups and early re-engagement Companionship/modeling of recovery lifestyle PIR led groups Peers in primary care settings Prevention Efforts Peer based prevention services for youth (e.g. community leadership councils) Peer based prevention services devoted to parents (e.g. train the trainers for parent wellness coaches) Involving youth in assessment and planning efforts for environmental strategies
Philadelphia’s First “Recovery Celebration” Conference
Recovery Walks! National Recovery Walk, Sept 2010
Building Block III: Fiscal and Administrative Policy & Procedures
Managed Care Levers for Promoting Recovery Credentialing Utilization Management Benefit Design & Supplemental Services Pay for Performance Programs Requests for Proposals Financing Mechanisms Training Programs
Building Block IV: Community and Cross- Systems Collaboration
CIT Training, Feb2008 Prolong exposure Therapy for Chronic PTSD Edna Foa, PhD March 2011 Training
Faith-Based Initiative skskskks Locations of Faith-Based Community Forums Broad Geographic Coverage 28 Faith-Based Community Forums and 766 other outreach events
We’ve come a long way (and a long way to go... ) The process can seem daunting and overwhelming, but it is possible! HOPE, coupled with broad based action, is key to moving beyond the status quo People in recovery are critical to leading this process and need to be engaged in multiple sectors of the system and community The process requires trust, collaboration and partnership – particularly between people in recovery, providers and system administrators Lessons Learned on the Road to Recovery Transformation
ANY DEAD HORSES IN OUR SYSTEMS?
Dakota tribal wisdom says that when you discover you are riding a dead horse, the best strategy is to dismount. However, in human services, we often try other strategies with dead horses, including the following:
Saying things like “This is the way we have always ridden this horse.”
Appointing a committee to study the dead horse.
Arranging to visit other sites to see how they ride dead horses.
Harnessing several dead horses together to establish a continuum of dead horses.
Creating trainings to ensure that we use best practices to ride the dead horse.
Changing the requirements: declaring “this horse is not dead.”
Declaring the horse is “better, faster and cheaper” dead.
Finding a consultant knowledgeable about dead horses.
Promoting the dead horse to a supervisory position.
THANK YOU! This is an exciting time in our field. Let’s enjoy the journey!
Resources DBHIDS Practice Guidelines for Treatment Providers Documents/transformation/PracticeGuidelines.pdf Additional Resources transformation